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151. Tetanus

Uncommon in the US; mostly in California, Texas, Florida (very low prevalence in high altitudes) in older patients with inadequate immunity. 11% mortality, more likely in the elderly.

Most cases related to acute wound or puncture wound; did not seek medical care or did not receive tetanus when seeking care.

Clostridium tetani, gram positive anaerobic rod. Creates indestructible spores that germinate into its toxin-producing form. Two toxins: tetanolysin which increases bacteria production and tetanospasmin, which is the neurotoxin.

Prevents release of glycine and GABA from presynaptic nerve terminals. Loss of inhibition. No person-to-person transmission.

Local tetanus: Just localized tetanus near wound; can progress to generalized.

Testing

Clinical diagnosis. Not really a good test. Wound cultures can grow the bug, but doesn’t mean you have tetanus. Serum antitoxin titers > 0.1 are protective, though there have been cases with normal levels. Consider checking urine strychnine to rule out strychnine poisoning.

Treatment

Usually ICU admission for respiratory monitoring. If intubated, may need to do neuromuscular blockade.

Human tetanus immunoglobulin (TIG) knocks out the circulating toxin, though does not neutralize the toxin already in the nerves. Helps reduce mortality. 3000-6000 units IM with some injected into wound. Do this before cleaning the wound bc toxin can be released during handling.

Wound Management: If unsure of previous 3-dose series, give TIG. If minor wound with low contamination, booster given if last booster was > 10 years. If contaminated wound, may need booster if last booster was > 5 years.